Major finding: The hernia recurrence rate was 1.7% in patients who underwent primary cruroplasty for hernias less than 5 cm in diameter and 1.1% in those who received mesh reinforcement because their hernias exceeded that size.

Data source: This was a retrospective study of 1,094 patients who underwent laparoscopic hiatal hernia repair since the investigators changed their threshold for utilizing mesh reinforcement from 8- to 5-cm hernia defects.

His coinvestigators had shown in an earlier randomized controlled trial that mesh reinforcement of primary cruroplasty in patients with a hernia of 8 cm or greater was associated with no recurrences. Repair with simple cruroplasty was associated with a 22% recurrence rate (Arch. Surg. 2002;137:649-52).

However, Dr. Aher and his coinvestigators subsequently observed a high recurrence rate following mesh-free simple cruroplasty for defects in the 5- to 8-cm range. He presented a case series involving 1,094 laparoscopic hiatal hernia repairs performed since he and his colleagues changed their practice by lowering their threshold for polytetrafluoroethylene mesh reinforcement to defects of at least 5 cm from their prior standard of 8 cm or more.

Hernias were less than 5 cm in diameter in 84% of the patients, so mesh wasn’t used for those repairs. In the remaining 178 patients – those with hernias of at least 5 cm – PTFE mesh was utilized to circumferentially reinforce the cruroplasty.

During a mean follow-up of 3.1 years, the hernia recurrence rate was 1.7% in the group with hernia defects of less than 5 cm and similar at 1.1% in those who received mesh reinforcement because their hernias were larger, reported Dr. Aher of Rush University Medical Center in Chicago.

Operative time and length of stay were longer in the mesh reinforcement group (see chart).

“There’s more dissection when using mesh, and obviously the placement of the mesh takes a little longer,” he noted at the meeting presented by the Society of Laparoscopic Surgeons and affiliated societies.

All repairs were performed using cruroplasty with interrupted nonabsorbable sutures approximating the right and left bundles of the right crura.

Dr. Chetan V. Aher

Laparoscopic repair has become the standard approach in the primary repair of hiatal hernias. In a 2010 survey of members of the Society of Gastrointestinal and Endoscopic Surgeons conducted by Dr. Aher’s colleagues, respondents indicated they laparoscopically performed 77% of their mesh-reinforced repairs. However, the survey results underscored a lack of consensus within the surgical community regarding mesh usage. Biologic mesh was used by 28% of surgeons; 25% used PTFE (polytetrafluoroethylene), and 21% polypropylene. Mesh placement practices also varied widely: 14% of surgeons utilized anterior placement, 34% posterior, and only 10% circumferential (Surg. Endosc. 2010;24:1017-24).

Asked how he counsels patients about the competing risks of mesh erosion and hernia recurrence in the absence of mesh reinforcement, Dr. Aher pointed to the 22% recurrence risk with large hernias in the earlier randomized trial.

“I would counsel my own family that if you have a large hernia, the risk of mesh erosion is very low and the risk of undergoing a recurrent operation if there is no mesh reinforcement is, I think, overall higher. So I would say they should get the mesh reinforcement,” he concluded.